Gender differences in perceptions and self-reported driving behaviors among teenagers.

BACKGROUND: The Centers for Disease Control reports that motor vehicle crashes (MVCs) are the leading cause of injury and death among U.S. teenagers, and disproportionately affect males. Among preventable causes of MVCs involving teenage drivers, distracted driving continues to be a serious public health problem. OBJECTIVES: To describe gender differences in teenage drivers' self-perceptions of safe driving behaviors, and self-reported risk behaviors and distractions while driving. METHODS: We prospectively surveyed teenage drivers from four high schools in Pennsylvania and New Jersey. Gender comparisons were made between self-reported perceptions and self-reported driving behaviors. Descriptive statistics and chi-squared testing were used in data analyses; significance was set at p < 0.05. RESULTS: Seven hundred fifty-six high school teenage drivers completed surveys. Males (52%) and females (48%) were equally distributed; 32% of males reported that they were extremely safe drivers, whereas only 18% of females reported that they were extremely safe drivers (p < 0.001). Significantly more females (91%) compared to males (77%) reported always wearing their seatbelts (p < 0.001). Female drivers were more likely than male drivers to self-report that they always make their passengers wear a seat belt (76% vs. 63%, p < 0.001). A higher proportion of males reported using their cell phones while driving, compared to females (68% vs. 56%, p = 0.004), and 42% of males reported texting while driving, compared to 34% of females (p = 0.037). CONCLUSION: Teenage male drivers perceive themselves to be safe drivers, but report engaging in more distracted driving and risky behaviors compared to females. These results suggest that there is an opportunity for gender-specific educational and injury prevention programs for teen drivers.

Using lean methodology to decrease wasted RN time in seeking supplies in emergency departments.

BACKGROUND: Timely stocking of essential supplies in an emergency department (ED) is crucial to efficient and effective patient care. OBJECTIVE: The objective of this study was to decrease wasted nursing time in obtaining needed supplies in an ED through the use of Lean process controls. METHODS: As part of a Lean project, the team conducted a "before and after" prospective observation study of ED nurses seeking supplies. Nurses were observed for an entire shift for the time spent outside the patient room obtaining supplies at baseline and after implementation of a point-of-use storage system. RESULTS: Before implementation, nurses were leaving patient rooms a median of 11 times per 8-hour shift (interquartile range [IQR], 8 times per 8-hour shift) and 10 times per 12-hour shift (IQR, 23 times per 12-hour shift). After implementation of the new system, the numbers decreased to 2.5 per 8-hour shift (IQR, 2 per 8-hour shift) and 1 per 12-hour shift (IQR, 1 per 12-hour shift). CONCLUSION: A redesigned process including a standardized stocking system significantly decreases the number of searches by nurses for supplies.

Patient attitudes regarding consent for emergency department computed tomographies.

INTRODUCTION: Little is known about patient attitudes towards informed consent for computed tomography (CT) in the emergency department (ED). We set out to determine ED patient attitudes about providing informed consent for CTs. METHODS: In this cross-sectional questionnaire-based survey study, we evaluated a convenience sample of patients' attitudes about providing informed consent for having a CT at 2 institutional sites. Historically, at our institutional network, patients received a CT at approximately 25% of their ED visits. The survey consisted of 17 "yes/no" or multiple-choice questions. The primary outcome question was "which type of informed consent do you feel is appropriate for a CT in the Emergency Department?" RESULTS: We analyzed 300 survey responses, which represented a 90% return rate of surveys distributed. Seventy-seven percent thought they should give their consent prior to receiving a CT, and 95% were either comfortable or very comfortable with their physician making the decision regarding whether they needed a CT. Forty percent of the patients felt that a general consent was appropriate before receiving a CT in the ED, while 34% thought a verbal consent was appropriate and 15% percent thought a written consent was appropriate. Seventy-two percent of the ED patients didn't expect to receive a CT during their ED visit and 30% of the ED patients had previously provided consent prior to receiving a CT. CONCLUSION: Most patients feel comfortable letting the doctor make the decision regarding the need for a CT. Most ED patients feel informed consent should occur before receiving a CT but only a minority feel the consent should be written and specific to the test.

Management of benign paroxysmal positional vertigo: a randomized controlled trial.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is a common presenting problem. OBJECTIVE: Our aim was to compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in patients presenting to the emergency department (ED) with BPPV. METHODS: This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who presented to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications and the second group received a canalith repositioning maneuver. The Dizziness Handicap Inventory was used to measure symptom resolution. RESULTS: Twenty-six patients were randomized; 11 to the standard treatment arm and 15 to the interventional arm. Mean age ± standard deviation of subjects randomized to receive maneuver and medication were 59 ± 12.6 years and 64 ± 11.2 years, respectively. There was no significant difference in mean ages between the two treatment arms (p = 0.310). Two hours after treatment, the symptoms between the groups showed no difference in measures of nausea (p = 0.548) or dizziness (p = 0.659). Both groups reported a high level of satisfaction, measured on a 0-10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9 ± 1.5 and 9 ± 1.0, respectively; there was no significant difference in satisfaction between the two arms (p = 0.889). Length of stay during the ED visit did not differ between the treatment groups (p = 0.873). None of the patients returned to an ED for similar symptoms. CONCLUSIONS: This pilot study shows promise, and would suggest that there is no difference in symptomatic resolution, ED length of stay, or patient satisfaction between standard medical care and canalith repositioning maneuver. Physicians should consider the canalith repositioning maneuver as a treatment option.

Training mothers in infant cardiopulmonary resuscitation with an instructional DVD and manikin.

CONTEXT: Classes in infant cardiopulmonary resuscitation (CPR) can be time consuming and costly. OBJECTIVE: To determine whether mothers in an obstetric unit could learn infant CPR by using a 22-minute instructional kit and to assess the value and confidence they gained by learning CPR. DESIGN: Quasi-experimental study with enrollment between January and December 2008. SETTING: Obstetric unit in Lehigh Valley Hospital, a suburban teaching hospital in Allentown, Pennsylvania. PARTICIPANTS: Mothers at least 18 years old who had given birth within the previous 24 hours. INTERVENTION: The experimental group included mothers without prior CPR training who watched a 22-minute instructional DVD and practiced on a manikin. The control group included mothers with prior conventional CPR training. MAIN OUTCOME MEASURES: In both groups, knowledge and proficiency were assessed with written and practical examinations developed by certified CPR instructors. Participant surveys were conducted at 3 times: immediately before dissemination of course materials, within 24 hours after the mother agreed to participate in the study, and 6 months after initial evaluation. RESULTS: A total of 126 mothers were enrolled in the study: 79 in the experimental group, 25 in the control group, and 22 who withdrew from the study. Written and practical examinations were used to determine proficiency, and composite scores were generated, with a maximum composite score of 12. The composite scores were statistically significantly higher in the experimental group than in the control group, with median scores of 10 and 7, respectively (P<.001). Twenty-two mothers (21%) had been previously offered CPR training. In the experimental group, 76 mothers (96%) felt more confident as caregivers after learning CPR. Before training in both groups, 84 mothers (81%) stated that learning CPR was extremely important, compared with 100 mothers (96%) after training (P=.001). CONCLUSION: Use of an instructional kit is an effective method of teaching CPR to new mothers. Mothers reported that learning CPR is extremely important and that it increases their confidence as caregivers.

Validation of a triage algorithm for psychiatric screening (TAPS) for patients with psychiatric chief complaints.

CONTEXT: The process of medical clearance screening for patients with psychiatric chief complaints has not been standardized. OBJECTIVE: To investigate the validity of a triage algorithm for psychiatric screening (TAPS) as a method to screen for the absence of acute medical illness in these patients. METHODS: The current study was a structured, retrospective medical record review in a suburban community teaching hospital with 37,000 emergency department visits per year. All ambulatory patients presenting to triage with a psychiatric chief complaint from January 31, 2001, to June 21, 2002, were assessed with TAPS. Patients with a completed TAPS and a negative assessment were identified and included in the study. A negative TAPS assessment comprised age younger than 65 years, normal vital signs, no medical complaints, no evidence of recent substance use, and no history of schizophrenia, mental retardation, or hallucinations. Emergency department records, return visit records, and inpatient admission records were reviewed for the diagnosis or management of acute medical illness. RESULTS: A total of 1179 patients were assessed with TAPS, of whom 825 (70%) had negative TAPS assessment and were eligible for inclusion. A random sample of 100 patients was selected from this group, with 7 exclusions. Sixty-six (71%) had a history of mental illness and 51 (55%) were admitted. Further, 25 (27%) had laboratory tests ordered, and none of the laboratory results required medical intervention. Twenty-nine patients (31%) received medication, mostly previously prescribed medications or sleep aids. None of the medications were for treating patients with violent or aggressive behavior. The average length of stay was 409 minutes. No patients (95% confidence interval, 0%-3%; P<.05) received a diagnosis of or treatment for acute medical illness. CONCLUSION: The TAPS form is potentially an effective tool in screening for the absence of acute medical illness.

Analysis of sex differences in preadmission management of ST-segment elevation (STEMI) myocardial infarction.

BACKGROUND: Many reports suggest gender disparity in cardiac care as a contributor to the increased mortality among women with heart disease. OBJECTIVE: We sought to identify gender differences in the management of Myocardial Infarction (MI) Alert-activated ST-segment elevation myocardial infarction (STEMI) patients that may have resulted from prehospital initiation. METHODS: A retrospective database was created for MI Alert STEMI patients who presented to the emergency department (ED) of an academic community hospital with 74,000 annual visits from April 2000 through December 2008. Included were patients meeting criteria for an MI Alert (an institutional clinical practice guideline designed to expedite cardiac catheterization for STEMI patients). Data points (before and after initiation of a prehospital alert protocol) were compared and used as markers of therapy: time to ECG, receiving ß-blockers, and time to the catheterization laboratory (cath lab). Differences in categorical variables by patient sex were assessed using the χ(2) test. Medians were estimated as the measure of central tendency. Quantile regression models were used to assess differences in median times between subgroups. RESULTS: A total of 1231 MI Alert charts were identified and analyzed. The majority of the study population were male (70%), arrived at the ED via ambulance (60.1%), and were taking a ß-blocker (67.8%) or aspirin (91.6%) at the time of the ED admission. Female patients were more likely than male patients to arrive at the ED via ambulance (65.9% vs 57.6%, respectively; P = 0.014). The median age of female patients was 68 years, whereas male patients were significantly younger (median age, 59 years; P < 0.001). The proportion of patients currently taking a ß-blocker or low-dose aspirin did not vary by gender. Overall, 78.2% of the MI Alert patients arriving at the ED were MI2 (alert initiated by ED physician), and this did not vary by gender (P = 0.33). A total of 1064 MI Alert patients went to the cath lab: 766 male patients (88.9%) and 298 female patients (80.8%). Overall, the median time to cath lab arrival was 79 minutes for men and 81 minutes for women (P = 0.38). Overall, the median time to cath lab arrival significantly decreased from MI1 to MI3, (P(trend) < 0.001). For prehospital-initiated alerts (MI3), the median time to cath lab arrival was the same for men and women (64 minutes; P = 1.0). For hospital-initiated alerts, time to cath lab arrival was 82 minutes for male patients and 84 minutes for female patients (P = 0.38). Prehospital activation of the process decreased the time to the cath lab by 19 minutes (P < 0.001; 95% CI, 13.2-24.8). CONCLUSION: No significant gender differences were apparent in the STEMI patients analyzed, whether the MI Alert was initiated in the ED or prehospital initiated. Initiating prehospital-based alerts significantly decreased the time to the cath lab.

Impact of education on physician attitudes toward computed tomography utilization and consent.

BACKGROUND: There are risks to ordering computed tomography (CT) scans. OBJECTIVE: We set out to determine whether emergency physician attitudes and their predictions of CT ordering behaviors could be influenced by education. METHODS: We surveyed emergency physicians at a Level I trauma center with a yearly census of 74,000. Physicians were given a baseline survey that encompassed demographics, attitudes toward CT informed consent, and ordering behaviors. After receiving an education session regarding CT risks, each participant received a follow-up survey. Data analysis was performed using frequencies and chi-squared. RESULTS: Seventy-five physicians participated; 69% residents and 31% attendings; 34% were female and 66% male. Thirteen percent reported they did not know if informed consent was required for CT scans obtained in the Emergency Department. Pre-education, 89% reported sometimes ordering a CT scan due to a consultant request that they felt was not indicated, and 92% reported that they sometimes ordered a CT scan to appease a patient or family. Eighty-five percent reported that they sometimes ordered a CT scan defensively due to malpractice risk. After education, physicians were more likely to believe a patient should give informed consent before CT (p<0.01) and predicted that they would be more likely to discuss the risks/benefits of CT with their patients all of the time (p=0.001). CONCLUSION: After education about the risks of CT utilization, emergency physicians were more likely to believe that patients should give informed consent before CT scan and predicted that they would be more likely to discuss the risks and benefits of CT with their patients.

Gender disparity in emergency department non-ST elevation myocardial infarction management.

BACKGROUND: Many studies have looked at differences between men and women with acute coronary syndrome. These studies demonstrate that women have worse outcomes, receive fewer invasive interventions, and experience delay in the initiation of established medical therapies. OBJECTIVE: Using innovative technology, we set out to unveil and resolve any gender disparities in the evaluation and treatment of patients presenting with a positive troponin while in the emergency department. Our goal was to assess the feasibility of using a business management query system to create an automated data report that could identify deficiencies in standards of care and be used to improve the quality of treatment we provide our patients. METHODS: Over a 12-month period, key markers for patients with non-ST elevation myocardial infarction (NSTEMI) were tracked (e.g., time to electrocardiogram, door to medications). During this time, educational endeavors were initiated utilizing McKesson's Horizon Business Insight™ (McKesson Information Solutions, Alpharetta, GA) to illustrate gender differences in standard therapy. Subsequently, indicators were evaluated for improvement. RESULTS: Substantial improvements in key indicators for management of NSTEMI were obtained and gender differences minimized where education was provided. CONCLUSION: The integration of these information systems allowed us to create a successful performance improvement tool and, as an added benefit, nearly eliminated the need for manual retrospective chart reviews.

Cardiopulmonary resuscitation prescription program: a pilot randomized comparator trial.

BACKGROUND: The American Heart Association wants to increase the number of citizens who know how to perform cardiopulmonary resuscitation (CPR). It is unknown whether giving patients a prescription (Rx) to learn CPR is effective. We sought to determine if patients with, or at risk for, heart disease and their families were more likely to follow prescriptive advice to buy a CPR Anytime™ kit (American Heart Association, Dallas, TX) or to take a CPR class. METHODS: This was a prospective randomized pilot study of a convenience sample of 162 patients who presented to one of three recruiting sites: a suburban community emergency department (ED), an office-based primary care (IM), or cardiology (CD) setting. After consent was obtained, CPR-naïve participants aged>44 years were randomized to one of two study arms. One group received a Rx for a CPR Anytime™ self-learning kit, consisting of a CPR mannequin and a 22-minute DVD. The comparator group was prescribed a CPR class. RESULTS: At the IM office, 7/29 (24%), at the CD office 3/25 (12%), and at the ED 2/23 (9%) patients purchased the CPR kit. Across both investigational arms, 4 were lost to follow-up, yielding approximately 15% (12/77) who followed Rx advice to purchase the CPR kit and 0% (0/79) who took a CPR class. Cumulatively, a participant was significantly more likely to purchase a kit than to take a class (p=0.0004). CONCLUSION: Patients can be motivated to purchase CPR Anytime™ kits but not to take a CPR class from prescribed advice.